Statistics show that about 1 in 5, or 20 percent of all Medicare patients are readmitted to hospital within 30 days of discharge. That’s a staggering number, not to mention all those patients that are readmitted frequently during the course of a year, but not necessarily within 30 days.

The problem of frequent hospital readmissions is actually one that exists all over the world and not just in the United States. Health care systems everywhere are seeking solutions to keep their patients healthier and away from hospital. Any doctor practicing at the frontlines will be able to tell you what a big issue this is right now. We regularly see the same patients on something of a merry-go-round of frequent hospital admissions, often with the same illness.

Why does this happen? This issue is complex. In my experience as a hospital medicine doctor, there are number of factors in play, falling into different categories according to the type of illness, availability of definitive treatment, and the social circumstances of the patient.

Severity of illness. Certain chronic conditions, such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), when in their advanced stages, are very labile and prone to exacerbations. As much as doctors try to control these with medications, it’s a very difficult task, as it only takes a slight precipitant such as a minor infection or dietary indiscretion to push somebody over the edge. By their very nature chronic diseases tend to get worse over time. And with an aging population, these conditions are increasing in prevalence. Unless we find definitive cures, hospitalizations are always unfortunately a possibility.

Social situation. Patients who have inadequate family support tend to be admitted to hospital more frequently for a couple of reasons. Firstly, their threshold for being able to cope at home with their illness is much lower. Secondly, they will not be able to co-ordinate their regular follow up care so easily. We see the effects of this all the time at the frontlines — two patients with the same level of illness severity; one will be managed at home, the other will require hospital admission for several days.

Lack of follow-up. Many studies have shown that lack of follow-up with a primary care physician in the weeks after discharge can lead to a higher likelihood of re-hospitalization. Seeing a doctor quickly post discharge allows for any potential problems to be “nipped in the bud”. It also allows for care co-ordination and medication reconciliation. Sadly, a large number of patients do not have a regular primary care doctor (mostly for insurance reasons). They therefore tend to use the emergency room as their first point of contact when they feel unwell again.

Suboptimal discharge process. By its’ very nature, the process of discharging a complicated patient from hospital is one that is fraught with possible problems. The discharge process needs to be thorough, seamless and diligent. Areas for improvement in most hospitals include medication reconciliation, clarifying follow-up appointments, follow-up laboratory tests, and making sure that the patient and family is clear about these instructions. Too often, this process is rushed and glossed over. Nothing beats having the doctor sit down with the patient and their family, spending time reviewing all the pertinent information.

Low health literacy. Many patients are not fully educated and informed about the nature of their illness and how best to manage it at home. This can be dealt with by regular reinforcement and utilizing home nursing services to keep on checking in with the patient post-discharge.

Certain very obvious patterns do exist in how patients tend to be readmitted to hospital. Several initiatives are underway across the country to try and improve the situation. Primary care doctors, specialty clinics, home nursing services, and even social workers are all being utilized as part of a team-based approach. The strategies broadly involve:

Identifying high-risk patients early

Educating the patient and involving family members

Having very close follow-up with a collaborative care team

As part of health care reform, hospitals are also facing financial penalties for consistently high readmission rates. But financial penalties alone aren’t the answer, especially for “safety net” hospitals that struggle more with this problem. It’s important to remember that the drive to reduce readmissions is not just about saving the health care system money, but ultimately about keeping our patients healthier and stronger. Whatever can be done to keep them at home enjoying life as much as possible instead of lying in a hospital bed, can only be a good thing.

Background

Social inequalities in health are a characteristic of almost all European Welfare States. It has been estimated, that this is associated with annual costs that amount to approximately 9% of total member state GDP. We investigated the influence of inequalities in German health care utilization on direct medical costs.

Methods

We used longitudinal data from a representative panel study (German Socio-Economic Panel Study) covering 1994 to 2010. The sample consisted of respondents aged 18 years or older. We used additional data from the German Health Interview and Examination Survey for Children and Adolescents, conducted between 2003 and 2006, to report utilization for male and female participants aged from 0 to 17 years. We analyzed inequalities in health care using negative binomial regression models and top-down cost estimates.

Results

Men in the lowest income group (less than 60% of median income) had a 1.3-fold (95% CI: 1.2-1.4) increased number of doctor visits and a 2.2-fold (95% CI: 1.9-2.6) increased number of hospital days per year, when compared with the highest income group; the corresponding differences were 1.1 (95% CI: 1.0-1.1) and 1.3 (95% CI: 1.2-1.5) for women. Depending on the underlying scenario used, direct costs for health care due to health inequalities were increased by approximately 2 billion to 25 billion euros per year. The best case scenario (the whole population is as healthy and uses an equivalent amount of resources as the well-off) would have hypothetically reduced the costs of health care by 16 to 25 billion euros per year.

Conclusions

Our findings indicate that inequalities and inequities in health care utilization exist in Germany, with respect to income position, and are associated with considerable direct costs. Additional research is needed to analyze the indirect costs of health inequalities and to replicate the current findings using different methodologies.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

“suffering or sick person,” late 14c., from O.Fr. pacient (n.), from the adj., from L. patientem

Alternatives to the term ‘patient’ like ’clients’, ’service users’ and ‘consumers’ have come about as a result of attempts to empower patients by changing their relationships with illness, society and the medical professions.

Calling patients ‘consumers’ is not the same as empowering them. It is very unlikely to change the prejudices associated with illness and disease because these are too deeply historically and socially embedded. The relationships between patients and medical professionals have evolved throughout history as traditional hierarchies have changed, patients have become better educated and medical professionals have been taught to be more patient-centred.

Whatever term we use to replace ‘patients’ is embedded in its own web of contexts. What we understand by ‘consumer’ or ‘client’ has changed in time, responding to pressure and criticism about the balance of power in the constituent relationships.

I believe that ‘patient’ is broad and evolutionary and the criticisms and attempts to replace it with other terms reveal important details about social attitudes. Rather than replace ‘patient’ with another term, it is vital that we understand and challenge what we mean by it.

The patient in a historical context.

Extract from ‘Disease and Social Life’ Henry Sigerist, Civilization and Disease 1943

The attitude of society to the sick man and its valuation of health and disease have changed a great deal in the course of history. … The present position of the sick man in society is very complex, the result of historical developments we must analyse briefly if we are to come to a clear view of the subject.

There are very few truly primitive tribes left in the world. Among them the Kubu of Sumatra seem to merit close study … minor diseases, skin eruptions wounds and similar ailments are frequent with them. People suffering from such diseases are not considered different from other tribesmen for their criterion is social not physical. As long as a man is able to live the life of his tribe his condition does not cause any reaction on the part of the individual or of society.

Things are different in the case of serious illnesses more especially those consisting of a fever such as smallpox … Such a patient finds himself unable to take part in the life of the tribe, he is incapacitated and there is a sharp reaction which leads to his abandonment by both the tribe and by his own kin … The sufferer is dead socially long before physical death has overtaken him.

In the case of tribes living in a higher state of civilisation however… the sick man is considered a victim, unable to live like other people because someone has worked upon him. An enemy has done something to him, has bewitched him … Thus the sick man has a special position in society, claiming the regard of his fellow men as well as their help. He is the guiltless victim of secret powers which are recognised and warded off by the medicine man.

…In the ancient Orient … the sick man was by no means an innocent victim but rather one who through his pain is making atonement for his sins. Disease then becomes a punishment for sin [and] we encounter his view in Babylonia and the Old Testament.

Where such a view prevailed the sick man found he burdened with a certain amount of odium. He suffered, but it was believed he suffered deservedly. His disease proclaimed his sin for all to see. He was branded and socially isolated in a particularly severe way. Disease however, was not only a punishment; it was also atonement for guilt, and thus redemption.

To the Greek of the 5th century and long thereafter, health appeared as the highest good. Disease therefore was a great curse … and by removing [man] from this plane of perfection, made him an inferior being. The sick man, the cripple and the weakling could only expect consideration from society so long as their condition was capable of improvement. The most practical course to take with a weakling was to destroy him, and this was done frequently enough. … The Greek physician would have considered it unethical to attend a hopeless case. Thus the sick man in Greek society also found himself burdened with an odium, not that of sin but of inferiority.

Christianity came into the world as the religion of healing… It addressed itself to the disinherited to the sick and afflicted and promised them healing, a restoration both spiritual and physical. Disease is no disgrace, is not a punishment for the sin of the sufferer or of others, nor does it render the patient inferior. On the contrary, suffering means purification and becomes grace. Illness is suffering and suffering perfects the sufferer; it is a friend of the soul…

The social position of the sick man thus became fundamentally different from what it had been before. He assumed a preferential position which has been his ever since.

The attitudes of society towards the sick that prevailed before the Christian era were never entirely overcome. In the Middle Ages and the Renaissance epidemics were very frequently considered visitations inflicted by God .. Until very recently there were still people who considered mental diseases a punishment for a disorderly life and venereal disease a singularly appropriate chastisement because the manifested themselves in the organs with which people had sinned. The old retributive view of disease is also expressed in the outraged feelings of patients who consider their sufferings as undeserved.

Sigerist brings his historical review of the role of the sick man up to the present day,

The sick man, because of his preferential position, finds himself released from many duties. … The more pronounced [this became] the more obvious was the inclination to escape from the struggle of life and to take refuge in the condition of illness.

This introduction is to give a taste, but by no means the full menu, of what it means to be a sick, and by extension a patient. What is striking is that as time goes by, like layers of paint on an old door, new meanings replace old ones, but the old ones remain underneath, coming to the surface through the cracks, often where and when we are not expecting them.

Brian’s old paper notes take up almost half a rack in the filing cabinet, filling the space taken up by the notes of at least half a dozen patients filed alongside. It makes me wonder about the concealment of complexity in the neat electronic patient records we use almost exclusively now, a full life’s history condensed into a front screen. Considering the weight of his records, he treads lightly and looks well. At least he does as he walks across the waiting room. Usually we talk about his latest trips to the dental hospital, the pain specialist and the neurologist, the physiotherapist and the psychologist; whichever he has seen recently. Most of them have been seeing him for years, helping him with his facial pain, muscle weakness and headaches. It wasn’t long ago that I invited him in to talk to my medical students about living with pain. Our consultations had included many discussions about the functional aspects of his symptoms -how they affect his ability to manage his daily activities, his relationships and his emotions and I felt I knew him very well. Nevertheless I had never asked Brian what the pain meant to him; he said he wasn’t sure what I meant, so I said, “some people believe that they are meant to suffer, that it is a punishment for something they have done, do you ever feel like that?”

“Oh yes”, he replied, immediately and confidently, “I know why I’m like this, and I know it’s not going to get better” He alluded to something long ago, but respectfully I didn’t press for details and he made it clear that we had gone far enough at that time. Since then we have discussed on many occasions the guilt that he struggles to resolve since his wife’s unexpected death many years ago. Though he is still in pain, he has stopped seeing two of his specialists and has halved the dose of his medications.

Illnesses have meanings that are imposed by history and culture. As patients we may find that we are unprepared for the meanings our illnesses take on. The writer and philosopher Susan Sontag wrote about this in relation to her experience of breast cancer in her book, ‘Illness as a metaphor’.

She is particularly concerned with the metaphorical issue of tuberculosis in the 19th century and cancer in the 20th. Most of these metaphors are lurid, and they turn each disease into a mythology. Until 1882, when tuberculosis was discovered to be a bacterial infection, the symptoms were regarded as constituting not merely a disease but a stage of being, a mystery of nature. Those who suffered from the disease were thought to embody a special type of humanity. The corresponding typology featured not bodily symptoms but spiritual and moral attributes: nobility of soul, creative fire, the melancholy of Romanticism, desire and its excess. Today, if Miss Sontag’s account is accurate, there is a corresponding stereotype of the cancer victim: someone emotionally inert, a loser, slow, bourgeois, someone who has steadily repressed his natural feelings, especially of rage. Such a person is thought to be cancer-prone. New York Times review 1978

Shortly after her book was published, AIDS was discovered and proved (as if there was any doubt) that illness was still a metaphor. Though the prejudices are fading I still have patients for whom the social and psychological burdens of being diagnosed with HIV or cancer cause far more suffering than the medical effects. Obesity, in being treated as an illness has been medicalised and carries the additional burden of being mythologised as a punishment for the twin sins of gluttony and sloth. By being medicalised it has gained the metaphor of an epidemic. But the most enduring discrimination and weighty metaphors remain for mental illnesses. The continued political rhetoric about the deserving and undeserving sick, the pressure to force people back to work and the fitness to work assessments by private IT company ATOS that pay scant attention to psychological factors add fresh layers to a long history of prejudice. Underpinning many of these metaphors is one of illness as psychological vulnerability; fearful of being or becoming vulnerable ourselves – we have a natural tendency to locate it in other people – it is he, not me, who is in need, it is she, not me, who is vulnerable.

A 2007 British Medical Journal article about illness and metaphor echoed Sontag, asking journalists and medical professionals ‘to collaborate in developing sets of metaphors that are factually informative and enhance communication between doctors and their patients’. Whilst well intended I suspect it is not only futile for elites to try to control metaphors which are socially and historically embedded, but there is something disturbing about the idea that elites might try or be able to control the metaphors we use.

Maureen looked after her mother for the last 2 years of her life. She had advanced dementia, renal failure and damage to the nerves in her feet – a consequence of her diabetes. She was in terrible pain … when she died Maureen was shattered, emotionally and physically. I referred her to a psychiatrist to for assessment to see if her memory loss was a sign of her own dementia or a consequence of her depression, but she did not attend the appointment, afraid of the answer whatever it might be. When a few months later she developed the first symptoms of diabetes we both knew that she was terrified of following in her mother’s footsteps. Within a few weeks she had developed pain in her feet, she described it exactly as her mother had -when she still had the ability to express herself. I knew that damage to the nerves happens only gradually after years of high blood sugar levels due to diabetes. For Maureen however the pain served to confirm her worst fears. ….

The relationship between patients and suffering and the labels that stick to them is so complex that it is not surprising that people refuse or are reluctant to be called patients.

Words used in diagnosis as a kind of biomedical revelation, are fixed in time; words used in narrative, as a revelation of the human condition, stretch across time.
‘we find that labelling is always a dangerous process … because it connotes problems as fixed or invariant.’

The relationship that many doctors like myself have with our patients is continuous and the ongoing narrative prevents our patients and ourselves becoming trapped within the words and the language that we use or that surrounds us. This is a theme I have written about before in, A world without health professionals and What is the role of a GP today? … that of a doctor who ‘bears witness’, acts as friend and comforter, confidant and counsellor. As Iona Heath explains in her book, A Mystery of General Practice,

… the key roles of a General Practitioner are firstly to stand as interpreter and guardian at the interface between illness and disease; and secondly to serve as a witness to a patients illness and disease.

By standing guard at the interface between illness and disease we are manning the gates between human suffering and a biomedical label.

Doctors and patients

The relationship between doctors and patients is integral to the term ‘patient’; the act of engaging with a medical professional transforms the person who is seeking help into a patient.

This transformation is centred in the consultation,

The real work of a doctor is only faintly realized by many lay people.
It is not an affair of health centres, or public clinics, or operating theatres, or laboratories, or hospital beds. These techniques have their place in medicine, but they are not medicine. The essential unit of medical practice is the occasion when, in the intimacy of the consulting room or sick room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it.

Just as the attitude of society to the sick man has changed over time, so has the relationship between doctors and patients,

The rapid growth of science in the 18th and 19th centuries led to the development of the physician as expert engineer of the body as machine. This state of affairs favoured principally, as we know, developments in microbiology and surgery. Concurrently, patterns of the doctor-patient relationship stressed the latter’s dependency and inferiority. … In treatment, the activity-passivity or at most the guidance-cooperation type of doctor-patient relationship prevailed. Szasz: The Doctor Patient Relationship and its historical context

This kind of medical paternalism is seen as distinctly old-fashioned and the last 30 years or more of medical education at the same time as,

‘the steady drift of social relations, toward increasing acceptance of, and often insistence upon ‘democratic’ or ‘socialistic’ (equalitarian) patterns of behaviour exerts -we assume- a pressure on medical relations to conform to a similar pattern wherever possible. (ibid)

These days patients are rightly seen as experts who have valuable lessons to teach the professionals. The relationship between doctors and patients has been the subject of considerable study, criticism and debate. Retired GP Dr Julian Tudor Hart sums up the situation we general practitioners (family doctors/ primary care doctors) in particular, have been working towards in his book The Political Economy of Healthcare,

Progress in health care depends on developing professionals as sceptical producers of health gain rather than salesmen of process, and on developing patients as sceptical co-producers, rather than consumers searching for bargains. Productivity in health care depends on complex decisions about complex problems, involving innumerable unstable and unpredictable variables. These decisions require increasingly labour-intensive production methods, with ever deeper, more trusting and more continuous relationships between professionals and patients.

The relationship between myself and my patients varies considerably from the idealised one of equal partnership and co-production. Many patients are unwilling or incapable of maintaining this kind of relationship, for example when they are severely demented or very young, acutely psychotic or critically unwell, addicted to drugs or intoxicated. At other times, my patients take the lead, guiding me and teaching me about their conditions. Recent examples have been patients with motor-neurone disease and adrenal insufficiency. Factors such as personality, psychology, disease status (unknown, deteriorating, recovering, recovered etc.) wealth, education, sex and social status, all influence the balance of knowledge, power and responsibility.

The ethical principle underpinning the doctor-patient relationship is ‘respect for patient autonomy’ where autonomy, literally means, ‘self government’ or the capacity to make decisions regarding one’s care. We must be careful here not to conflate ‘individual autonomy’ with ‘relational autonomy’, which is capacity that arises from the relationship rather than the individual. I have explored it in more detail in another post about patients and consumers. The social trend and a powerful myth of our time is one of increasing individualism, whereby we are lead to believe in the possibility of ever-increasing personal (not social) freedom and individual (not relational) autonomy.

One consequence of this myth is that there has been a shift in the situation of health prevention from the societal level to the level of the individual. If politicians and medical professionals were interested in evidence-based public health measures they would be tackling the food, alcohol and cigarette industries, increasing the possibilities for exercise by making streets safer and reducing social and economic inequality. But instead, we are forced to deal with the consequences of social problems in our consulting rooms and operating theatres; handing out expensive, ineffective and frequently dangerous prescriptions for addictions and obesity. My patients are admonished for not taking more responsibility for their health at the same time as I am told that I need give my patients more responsibility.

The aim of government today, of all parties, is to shift the burden of responsibility as far downstream as possible. But in a time of widening inequalities, while the responsibility for change is being shifted downstream, power is being shifted up. Responsibility without power or resources with which to act leads to helplessness and is disempowering.

The idea behind this is that health is individually, not socially determined and the role of the doctor is not so much about sharing responsibility as handing it back to patients. Part of this motivation is to diminish the role of the GP so that anyone or anything (smartphone?) can take over (see The Myth of the Trivial consultation) The reductionism of the doctor-patient relationship is part of a wider process of ‘atomisation’ in which the steady politically motivated criticism of human interdependency is leading to increasing individual isolation. In health care this is seen as shift away from a GP of your own towards triage and nurse-practitioners, walk-in centres and telehealth. In hospital care towards mega-hospitals, increasing specialisation, and ‘Assembly line efficiency’. In nursing towards minimally trained nursing assistants and the denigration of the role of personal care. In every job, this leads an ideological point of view, that health care is like any other industry and each job can be compartmentalised and professionals with a holistic approach to the whole patient may be replaced by technicians.

The doctor-patient relationship has in and of itself a powerful therapeutic dimension and I think that is what Sir James Spence meant when he said, The real work of a doctor is only faintly realized by many lay people (ibid). This is faintly realised and under acknowledged because we live in a technophiliac society, enthralled by the possibility of a dehumanised, de-socialised, de-politicised technical or chemical solution to our problems. Human relationships are demeaned and undervalued, in part because medicine has become subjugated to the market and human relationships are harder to commodify than technical interventions or sedative drugs. The trivialisation of relationships is not new. The word Trivia stems from the word for the three arts of communication; rhetoric, grammar and logic. These were worthy of lesser respect than the ‘quadrivia’; arithmetic, geometry, music and astronomy, the skills of science. The split harks back ancient Rome, and the trivia were the lower arts, ‘only of interest to the undergraduate.’ The continuing hammer and tongs barney between the evidentiologists and the social scientists is a dangerous distraction from the political motives.

Rejecting the patient label.

The idea of the sovereign individual is so powerful that one reason for rejecting the label patient is to prove that we don’t need others. Just as refusing to be called a diabetic is a refusal to be defined in terms of an illness, refusing to be called a patient is a refusal to be defined in terms of a relationship, particularly one that implies dependency.

Psychotherapists and psychologists who have almost universally ditched the term patient in favour of client. Their rationale is that ‘client’ does not have the historical baggage of medical paternalism. It is also about affirming their difference from psychiatrists (medically trained doctors who prescribe drugs to patients rather engage clients in talking therapies)

There are other reasons for rejecting the patient label. In recent decades there has been an ever-widening of disease categories to include the ‘not yet sick’, such as those with hypertension, high cholesterol etc. driven by a medical-industrial complex that profits from defining ever-higher proportions of ever-healthier populations as in need of medication. They are not in any reasonable sense, suffering, though the drugs can cause unpleasant and rarely fatal complications.

We also care for those with chronic conditions such as diabetes, heart disease or even cancer or mental illnesses that are quiescent or in remission. They have no symptoms of illness and are not in any obvious way suffering or sick and yet we call them ‘patients’. We are much less inclined to define patients by their illnesses with labels like ‘diabetics’ or ‘schizophrenics’ because it is clear that the individual experience of living with a condition is so variable as to make this kind of label an insult to the holistic (whole person) care we strive to provide.

Patient and consumers

In many situations, patients do act as consumers; they research, demand and negotiate the care they want, seek second (or more) opinions, try treatments, reject them and try others, pay for preferential treatment, demand refunds or other recompense, have rights and so on. But there are important differences. There is a differential in knowledge and responsibility. My patients are free to harm themselves by consuming cigarettes and alcohol, junk-food and crack cocaine, but if they demand medical treatment that I believe to be harmful, or even ineffective I am not obliged like the shop-owner or drug-dealer to concede to their demands. Since I only see NHS patients, no amount of money will persuade me to treat the rich man better than the poor woman. This is one reason why the NHS is so cherished and trust in doctors is so high; patients believe that they are treated fairly. I am trained to recognise my patients’ unmet needs; when they come in wanting something to help them settle their stomach, by virtue of my expertise I can recommend self care, a tablet, an enema, a scan or a referral for emergency surgery depending on their signs and symptoms. I am not obliged to consider them as an opportunity for profit or loss. Perhaps the simplest way to describe the difference is that with a consumer one asks, ‘what can I do for you?’ and with a patient one asks the question, ‘what’s going on?’

“I always projected my worries onto my thyroid or physical problems, I knew deep down that it was my husband and his drinking, my mother who had suffered panic attacks all her life, who basically I’ve always had to be a mother to … but it was much easier to talk [to my GP] about physical problems, and then they say, that yes they can help with the symptoms and I thought, well maybe I don’t need to bring up all the other stuff, because there’s nothing I or the doctor can do about it anyway”

A consultation is never trivial. Every interaction is an opportunity to build up a relationship of trust and mutual respect so that when serious illness strikes, we are faced with someone we know.

When Jenny came in to see me with a rash on her stomach all she wanted was a different cream from the one she had been using, something stronger to clear it up. She looked pale even though her face was flushed. The ‘rash’ consisted of swollen veins, like small purple worms just under the skin; her liver was enlarged and irregular. All the signs suggested disseminated cancer. Jenny the woman with a rash, became Jenny, my patient.

Whilst patients clearly act as consumers in many ways, there are many ways in which they do not. And one important function of the NHS is that it means that we do not pay for the care we need. This is vitally important because the poorer you are the more likely you are to suffer from illnesses. And yet in a crucial development the Health and Social Care Bill will change that with the introduction of Personal Health Budgets.

People receiving continuing healthcare support from the NHS will have the right to ask for a personal health budget, by April 2014 Health Secretary Andrew Lansley announced today. … The announcement follows the independent NHS Future Forum report which recommended action to promote personal budgets and implement them within five years to give patients access to tailored services.

Personal Health Budgets are designed for patients with long-term conditions and include all aspects of care except GP and emergency visits. They may be spent on a manicure, laptop, fruit and veg or gym-membership. Clearly patient’s with their own financial resources will be paying for these things already and not relying on a money from the cash-strapped NHS whereas patients with much less money have to choose between these items and physiotherapy, speech therapy, personal care or medical equipment. Given this responsibility there is now for the first time in the history of the NHS, the possibility that a patient will have to pay for essential care when their personal budget has run out. BloggersRichardblogger and Kate Thomson have discussed PHB in more detail.

The government are in no doubt that patients should act more like consumers. The Office of Fair Trading said,

“It is important that patient demand and choice are able to drive competition and innovation in this market with a view to better value for all patients” John Fingleton, chief executive of the OFT

The over-arching theme was the belief that choice and information were the key drivers of competition and innovation in healthcare markets, improving patient outcomes and efficiency in patient care.

What happens when patients become consumers?

When patients are treated as consumers rather than patients to whom we have a duty to work with, we risk a return to the days before the NHS described byGeorge Bernard Shaw over a century ago:

… as doctors they pay unnecessary visits; they write prescriptions that are as absurd as the rub of chalk with which an Irish tailor once charmed away a wart from my father’s finger; they conspire with surgeons to promote operations; they nurse the delusions of the malade imaginaire (who is always really ill because, as there is no such thing as perfect health, nobody is ever really well); they exploit human folly, vanity, and fear of death as ruthlessly as their own health, strength, and patience are exploited by selfish hypochondriacs. They must do all these things or else run pecuniary risks that no man can fairly be asked to run. And the healthier the world becomes, the more they are compelled to live by imposture and the less by that really helpful activity of which all doctors get enough to preserve them from utter corruption. For even the most hardened humbug who ever prescribed ether tonics to ladies whose need for tonics is of precisely the same character as the need of poorer women for a glass of gin, has to help a mother through child-bearing often enough to feel that he is not living wholly in vain.

Treating patients as consumers shifts the paradigm from healthcare as a public good to healthcare as a commodity. Furthermore, when I think about patients, I think about ‘my patients’. This is because I have a list of patients for whom I am responsible. I know how many patients I have with diabetes, cancer, depression, heart disease and so on. I know which ones need to be visited at home and who is expected to die. I know who is due to give birth and who has just been born. When I see my patients I do not have to think about how much I could earn or save from each one, by arranging or refusing a referral. Time spent exploring a problem is at least as valuable as time spent arranging a referral.

In summary.

Patient is a term that is loaded with historical, sociological and political significance in terms of its relationship with disease, society and health professionals. Rejecting it is in part an attempt to tackle the associated disempowerment and balance unequal relationships.

Whilst well-intentioned this rejection has been co-opted by modern neo-liberal capitalist ideology. This dis-empowers individuals by devolving responsibility at the same time as widening economic inequality and undermining social solidarity. True patient empowerment comes from the process of co-production within a respectful therapeutic relationship. The term ‘patient’ is both flexible and resilient enough to stand above all the alternatives. It allows patients to be clients and consumers, to teach and be taught, to refuse care and be cared for. It recognises that doctors and patients are stronger when they work together and it confers on doctors a duty of care that is a vital part of the doctor-patient relationship.

IDEAS

Patients (the sick) have always been socially excluded in some way, and the label ‘patient’(in contrast to client/ consumer/ customer etc.) identifies the person as being sick. Refusing the label is both a denial and a way to insist on inclusion

Conditions such as infectious diseases e.g. TB, and STIs, Cancer and in particular mental illnesses are the most socially stigmatising. Psychiatry / psychology are the most resistant to ‘patient’ preferring client/ service user/ etc.

Alternatives client/ service user/ customer/ consumer have even more baggage than patient

The relationship with doctors

Paradoxically, the social trend is one of increasing individualism, whereby we insist on personal (not social) freedom and individual (not relational) autonomy. The consequence is that we are expected to stand on our own two feet, unaided by others or society. Rejection of the label patient is an insistence that we don’t need others.

Another social trend is the widening of disease categories to include the ‘not yet sick’, those with hypertension, high cholesterol etc. And also those with chronic conditions such as diabetes who have no symptoms of illness and do not in any way feel sick.

When doctors treat patients as consumers they may treat them as a means to an end.

The relationship between patients and carers is bound up in social and historical matricies and so is constantly in flux

The term patient is flexible enough to cope with these different contexts

The only fixed concept with patient is one of a relationship with a care-giver

Trivia is rhetoric, grammar and logic, the skills of communication, contrasting with quadrivia, arithmetic, geometry, music and atrostonomy, the skills of science. The split happened in ancient Rome, and the trivia were the lower arts, ‘only of interest to the undergraduate.’ This split is enduring, and increasingly we live in a technophiliac society, enthralled by the possibility of a technical solution to all our problems. Human relationships are demeaned and undervalued, in part because as medicine becomes more subjugated to the market, relationships are harder to commodify than technical interventions.

SMOKERS will be asked to quit before undergoing surgery and be referred for help while on waiting lists under new medical guidelines.

A strengthened smoking policy from the Australian and New Zealand College of Anaesthetists will require all elective surgery patients to be asked if they smoke, and for tobacco users to be given referrals to help them quit before their operations.

The policy will not give practitioners the power to delay or cancel surgery. But ANZCA president Dr Lindy Roberts said the guidelines would offer smokers the best chance to avoid life-threatening complications by providing them with support.

The hope is to convince and help smokers to quit four to six weeks before surgery, while they are already on the waiting list, which can greatly cut the risks of serious complications during recovery.

“Smokers are at greater risk of complications such as pneumonia, heart attacks and wound infections,” Dr Roberts said.

“When you are coming into hospital for something like an operation, it does provide you with an opportunity to think about your health more generally, and the benefits of giving up smoking for your health are in the longer term as well as relating to surgery and anaesthesia.

“It may be that when presented with the risks for a certain procedure that the surgery is delayed to allow somebody to improve their health prior to the surgery.

“From time to time a decision may be made between the anaesthetist, the surgeon and the patient to delay the surgery if there is something that can be improved to make them fitter for surgery.”

The move follows the success of a Frankston Hospital program in which all smokers entering the surgery waiting list were sent a quit pack – prompting 13 per cent to act and contact Quitline. Australian Medical Association Victorian president Victoria president Dr Stephen Parnis said the college’s quit-smoking stance was a positive move, balancing the need to advise patients without discriminating.

“This is not about banning people, this is about giving them the best chance to benefit,” Dr Parnis said. “When you weigh into account the procedure they need and their health, if there is a benefit to delaying the procedure then we would do that.”

(Reuters Health) – Close to one-quarter of colonoscopies performed on older adults in the U.S. may be uncalled for based on screening guidelines, a new study from Texas suggests.

Researchers found rates of inappropriate testing varied widely by doctor. Some did more than 40 percent of their colonoscopies on patients who were likely too old to benefit or who’d had a recent negative screening test and weren’t due for another.

Guidelines from the U.S. Preventive Services Task Force, a government-backed panel, recommend screening for colon cancer – every 10 years, if it’s done with colonoscopy – between age 50 and 75.

After that point, “It involves an unnecessary risk with no added benefit for these older patients,” said Kristin Sheffield, the new study’s lead author from the University of Texas Medical Branch in Galveston.

Those risks include bowel perforation, bleeding and incontinence, as well as the chance of having a false positive test and receiving unnecessary treatment.

Even for screening tests that are universally recommended for middle-aged adults, the balance of benefits and risks eventually points away from screening as people age. Any cancers that are caught might never have shown up during a patient’s lifetime if the person is too old or the cancer too slow-growing.

But because there has been so much effort to educate the public about reasons to get screened, the potential harms are often overlooked – and the idea of stopping screening isn’t regularly discussed, researchers said.

Sheffield and her colleagues looked at Medicare claims data for all of Texas and found just over 23 percent of colonoscopies performed on people age 70 and older were possibly inappropriate.

For patients age 76 to 85, as many as 39 percent of the tests were uncalled for, the researchers wrote Monday in JAMA Internal Medicine. The rest were likely done for diagnostic purposes.

A MORAL OBLIGATION?

Another study published in the same journal supports the idea that many Americans are so focused on the possible benefits of screening that they don’t realize harms are involved as well.

Dr. Alexia Torke from the Indiana University School of Medicine in Indianapolis and her colleagues surveyed 33 adults between age 63 and 91 and found many saw screening as a moral obligation.

Few of the older adults had discussed the possibility of stopping routine screening, such as for breast cancer, with their doctor, and some told the researchers they would distrust or question a doctor who recommended they stop.

“There’s very limited data for any cancer test that it leads to any benefit for older adults,” said Dr. Mara Schonberg, from Beth Israel Deaconess Medical Center and Harvard Medical School in Boston.

“You want to be doing this thinking it’s going to be helping you live longer,” she told Reuters Health – especially because the chance of suffering side effects from screening or treatment may be higher among older people.

Schonberg, who wrote a commentary on Torke’s study, said time spent unnecessarily screening older adults may take away from conversations that could actually benefit their health – such as about exercise and eating better.

“There’s really a strongly held belief that you need to get screened, that it’s irresponsible if you don’t,” said Dr. Steven Woloshin, who has studied attitudes toward screening at the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire.

“There have been all these messages for years about the importance of screening that people have been inundated with, and I think it’s really hard to change the message now, even though it’s become clear that screening is a double-edged sword,” Woloshin, who wasn’t involved in the new research, told Reuters Health.

The researchers agreed screening should be an individual decision as people get older, but that everyone should fully understand what they stand to gain – if anything – and what they could lose by getting screened.

For colon cancer in particular, Sheffield recommended elderly people who really want to be screened go with a less-invasive method than colonoscopy, such as fecal occult blood testing.

OVERUSING ANESTHESIA?

In another analysis of Medicare beneficiaries undergoing colonoscopy, researchers led by Dr. Gregory Cooper from Case Western Reserve University in Cleveland learned the proportion of procedures using anesthesia – most likely propofol – increased from less than nine percent in 2000 to 35 percent in 2009.

The cost of a procedure using anesthesia is about 20 percent higher than one without it, the researchers noted.

Patients in their study suffered a complication – including perforation or breathing problems – during one in 455 procedures using anesthesia, compared to one in 625 without anesthesia. The researchers said so-called deep sedation may impair patients’ airway reflexes and blunt their ability to respond to procedure-related pain.

During the year after an influential U.S. task force advised providers to stop routine screening colonoscopies in seniors over age 75 because risks of harm outweigh benefits, as many as 30% of these “potentially or probably inappropriate” procedures were still being performed, with huge pattern variation across the nation, especially in Texas.

“We found that a large proportion of colonoscopies that are performed in these older patients were potentially inappropriate based on age-based screening guidelines,” says Kristin Sheffield, PhD, assistant professor of surgery at the University of Texas Medical Branch at Galveston, lead researcher of the study.

For patients between 70 and 74, “procedures were repeated too soon after a negative exam,” increasing the odds of avoidable harm, such as “perforations, major bleeding, diverticulitis, severe abdominal pain or cardiovascular events,” she says. The guidance, from the U.S. Preventive Services Task Force, which was released in 2008, also set a 10-year interval for routine colonoscopies for people between age 70 to 75 unless the patient develops certain symptoms.

The task force’s prior guidance issued in 2002 had no age limit recommendation, Sheffield says.

“For some physicians, more than 30% of the colonoscopies they performed were potentially inappropriate according to these screening guidelines,” she says. “So this variation suggests that there are some providers who are overusing colonoscopy for screening purposes in older adults,” Sheffield said.

Her report, published in this week’s JAMA Internal Medicine,looked at Medicare data from the Dartmouth Atlas between October 1, 2008 and September 30, 2009, to see hospital referral region patterns of variation across the nation as a whole. For the state of Texas, Sheffield used claims data from smaller hospital service areas, so she could see practices of individual physicians who performed colonoscopies.

She discovered that Medicare beneficiaries were much less likely to have a “potentially or probably inappropriate” colonoscopy if they lived in a non-metropolitan or rural area. Practitioners who were more likely to perform potentially or probably inappropriate colonoscopies were more likely to have been graduated from medical school before 1990 rather than after, and were more likely to perform a higher volumes of the procedure on Medicare beneficiaries each year.

The data was de-identified, so as not to reveal the practice pattern of an individual physician by name.

“Our purpose was not to point fingers at individual physicians or specialties. We just wanted to examine patterns in potentially inappropriate colonoscopy, because patterns can illustrate issues in everyday practice. It can help illuminate and show the range of practice in terms of the range of inappropriate colonoscopies.

Sheffield says that it may be that colonoscopists were simply slow to adapt the recommendations to their practices in certain parts of the country. In a subset of cases, she acknowledges, there may have been legitimate reasons why a physician recommended the procedure in a patient, and perhaps failed to code it properly for the claims database.

“For example, in adults between the ages of 76 to 85, there are some considerations that would support the use of screening colonoscopy, for example, a patient has a higher risk of developing an adenoma. But in general, screening guidelines indicate that should be exception, rather than the rule.”

And if that were the case, there wouldn’t be such a huge variation. For example, in the wedge of west Texas that includes El Paso, the percentages of colonoscopies that were potentially inappropriate was between 13.3% and 18.79%. But in large areas including Austin, Corpus Christi, San Antonio Houston, and Waco, the percentages ranged between 23.3% and 34.9%.

Nationally, areas of higher potentially inappropriate colonoscopies­—with rates between 25.27% and 30.51%— included eastern Washington state, Idaho, and eastern Nevada, Minnesota, parts of North and South Dakota, all of New England, Arkansas and large portions of North Carolina and Tennessee.

Low utilization areas—with rates between 19.45% and 22.64% — included New Mexico and north Texas, Central and Northern Inland areas of California, and all parts of Florida except Pensacola and areas of South Florida.

The issue included a related article and related commentary.

In the related article, Alexia M. Torke, MD, and colleagues, of the Indiana University for Aging Research, interviewed several dozen patients about their reasons for screening. They found that these patients considered screening at their age to be an automatic part of healthcare, and “a moral obligation.”

For example, one told investigators that discontinuation of routine colonoscopy screening, at age 84, “would be the same as me taking my life. And that’s a sin.”

Discontinuation would mean a much more difficult and significant decision they would have to make.

And they were skeptical of recommendations that they should not have screening, saying it would threaten their trust in their doctors and make them suspicious that a guideline they shouldn’t be screened was made only to save money.

“Public health education and physician endorsements (of cancer screening) may have created a high degree of ‘momentum’ for continuation screening, even in situations in which the benefits may no longer outweigh the risks or burdens.”

In an invited commentary, Mara Schonberg, MD, MPH, of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, noted that as much as colonoscopies are celebrated as a preventive therapy, they also cause harm.

“Harms of cancer screening are immediate and include pain and anxiety related to the screening test, complications…(e.g., bowel perforation from colonoscopy,) or additional tests after a false positive result, and overdiagnosis (finding tumors that would never cause symptoms in an older adult’s lifetime). Overdiagnosis is particularly concerning because some older adults experience significant complications from cancer treatment.”

She blames “unbalanced public health messages” for contributing to “perceptions that cancer screening should be continued indefinitely,” she also points to the physician’s recommendation as a strong driver of whether a senior citizen undergoes one.

Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.

The Agency for Healthcare Research and Quality (AHRQ) has identified the top 10 patient safety strategies (PSSs) ready for immediate use. Paul G. Shekelle, MD, PhD, from the RAND Corporation, Santa Monica, California, and colleagues present the list in a special supplement to the Annals of Internal Medicine published online March 4. These interventions, if widely implemented, could dramatically enhance patient safety and save lives by reducing medication errors, bed sores, and healthcare-associated infections.

“Wide-scale reductions in patient harm have been modest despite over a decade of research, improvement, and effort since the Institute of Medicine’s ‘To Err is Human’ report,” Patrick W. Brady, MD, told Medscape Medical News in an email interview. “Since that report, the evidence base for safety strategies has continued to grow, but great challenges exist in taking these strategies to scale throughout health systems,” said Dr. Brady, an assistant professor in the Division of Hospital Medicine and the James M. Anderson Center for Health Systems Excellence, Department of Pediatrics, University of Cincinnati, Ohio, who was not involved in the AHRQ project.

According to a journal news release, diagnostic errors result in between 44,000 and 80,000 annual deaths in the United States alone, and bed sores lead to another 68,000 deaths. Thousands more patients die each year as a result of communication errors or failure to receive evidence-based interventions.

During the last 4 years, Dr. Shekelle and colleagues conducted an evidence based assessment of PSSs, including 79 strategies identified in the 2001 AHRQ report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices. On the basis of that assessment and subsequent input from clinicians, researchers, and policymakers regarding the epidemiology of errors and preventable harms, the investigators identified the top 10 PSSs, as well as 31 additional PSSs.

“The team of patient safety experts who put this list together are among the most respected safety experts in the world,” Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association, told Medscape Medical News in an email interview. “The strategies they have identified are effective, important, and should be on the top of every healthcare leader’s list for consideration.”

AHRQ’s Top 10 Patient Safety Strategies

preoperative and anesthesia checklists to reduce operative and postoperative events;

bundles including checklists to reduce septicemia associated with central lines;

“It is as important for hospital and health system leaders to know why some strategies are not on the list as to know what is on the list,” Foster said, wondering about the absence from the list of adoption of electronic health records despite robust decision support. “Is the evidence still emerging? Were they concerned about emerging evidence of some of the risks from use of [electronic health records]?”

Dr. Brady largely agreed with the list but noted that it could be the “source of some spirited debate.” He commended AHRQ for recommending strategies supported by excellent systematic review and/or research designs including randomized trials and comparative effectiveness studies.

“The considerations used by the authors [regarding] scope of problem addressed, strength of evidence of strategy effectiveness, potential for unintended consequences, cost, and difficulty of implementation are logical and will advance the field of patient safety science,” Dr. Brady said.

Implications for Patient Safety

Foster identified 3 challenges to finding the underlying causes of medical errors and strategies for reducing them: budget cuts affecting AHRQ research, rarity of some errors hindering determination of causes and solutions, and multiple causes underlying some errors, which necessitate use of bundled strategies.

“Medical errors are a worldwide problem that can affect many, many patients and their families, and the AHRQ has safety research as one of its missions, but its entire budget is miniscule compared to that of [the National Institutes of Health], and within AHRQ, patient safety is…only one of the important components,” Foster said. “If we want to resolve the problem, we need a sustained and significant investment in patient safety research, which would mean increasing AHRQ’s budget even in this era of federal budget cuts.”

The payoff could be dramatic. The American Hospital Association recently reported that their Hospital Engagement Network of nearly 1600 hospitals had a 40% reduction in central line bloodstream infections using the bundle recommended by AHRQ, and preliminary results on the implementation of the catheter-associated bloodstream prevention bundle appear to be equally promising.

Barriers to improving patient safety may include failure of health systems to implement complex, behavior-based interventions, as influenced by organizational leadership and culture. Dr. Brady recommends additional research in this area.

“An additional challenge to the successful implementation of safety strategies at individual hospitals may be the increasingly long list of ideas to improve patient safety,” Dr. Brady noted. “As this field has no shortage of good ideas, it may be challenging for hospital boards and patient safety leaders to determine where to focus. This rigorously developed, evidence-based top 10 is an important step to help healthcare administrators, clinicians, and researchers best target their efforts to improve patient safety now.”

“Fundamentally, we need to know more about what causes harm to patients and which strategies are effective in preventing them,” Foster concluded.

The AHRQ supported development of their report. Dr. Brady and Foster have disclosed no relevant financial relationships. Some of the report and editorial authors have disclosures involving the National Institutes of Health Research Collaborations for Leadership in Applied Health Research and Care for Birmingham and the Black Country; ECRI Institute; Veterans Affairs; AHRQ; Centers for Medicare & Medicaid Services; National Institute of Nursing Research, Office of the National Coordinator; UpToDate; Cantel Medical Group; Association for Professionals in Infection Control and Epidemiology, Hospitals and Health Care Systems; National Institutes of Health; Leigh Bureau; Penguin Group; American Board of Internal Medicine, Salem Hospital; Lippincott, Williams & Wilkins, McGraw-Hill; QuantiaMD; PatientSafe Solutions, CRISI, EarlySense; John Wiley and Sons; Marc and Lynne Benioff; United States–United Kingdom Fulbright Commission; RAND Corporation; and/or more than 100 other healthcare organizations including hospitals, healthcare systems, and state medical and hospital associations. Full conflict-of-interest information is available on the journal’s Web site.

If you think that medical errors are a thing of the past, you are mistaken.

It has been 14 years since the Institute of Medicine’s report “To Err Is Human” shattered the myth that most, if not all, physicians are all-knowing practitioners with flawless skills and infallible judgment.

The story of what happened in the report’s wake was predictable:

Where the healthcare industry failed to act as it should have, the federal government and accrediting organizations stepped in to set the standards for healthcare quality and safety, establish quality measures, and assure that healthcare delivery entities complied by instituting financial and other penalties for poor performance.

Patients who previously felt safe began to question their healthcare providers.

We began to see some evidence of improvement in the quality and safety of healthcare services across the U.S.

In light of the foregoing, a recent “trip” to the website for American Medical News, the newspaper of the American Medical Association, left me feeling frustrated and sad.

A story by Kevin B. O’Reilly referred to a recent well-referenced article in Surgery, noting that, at the close of last year, “never events” continue to occur in U.S. operating rooms 80 times per week.

In addition to causing temporary or permanent harm to patients, he extrapolated that these events carry a financial burden of almost $1.3 billion over 20 years.

Although surgical “never events” are rare (i.e., one in every ~12,000 procedures), their seriousness should not be diminished — especially when simple checklists and protocols have been shown to reduce the occurrence of such mistakes to near zero.

According to the article, published findings of a review of medical liability settlements and judgments collected in the National Practitioner Data Bank for 1990 to 2010 revealed that surgeons of all ages are involved in “never events” such as inadvertently leaving surgical items in the patient, performing either the wrong procedure or the right procedure on the wrong site, and — most egregious of all — operating on the wrong patient.

Startling as this is, previous studies have found that the 90% of injured patients who do not receive indemnity payments are not even included in the data bank.

Other studies have shown that “never events” can be eliminated — or at least minimized — by intensifying focus on identifying and correcting deficient processes, for example by addressing communication lapses with presurgery briefings and marking operative sites.

To its credit, the Joint Commission’s Center for Transforming Healthcare launched a project in 2010 to reduce wrong-site surgery risk at eight healthcare organizations and to provide tools to help others prevent these mistakes.

After these organizations reduced the proportion of cases in which there was a process-related problem that could have resulted in a wrong-site surgery from 52% to 19%, the commission made a wrong-site surgery prevention toolkit available to its accredited hospitals at no cost.

A national surgical safety project — NoThing Left Behind — introduced a slight change in the process for counting sponges at the end of procedures and some organizations have adopted new technologies (e.g., bar-coded sponges) to address the problem of retained foreign bodies.

Despite these and other evidence-based efforts, surgical “never events” continue to occur at the rate of 4,160 every year.

Because patient safety is part and parcel of my daily routine — whether in the hospital, the classroom, or at a national meeting — I ask myself why our industry is not mortified and why, as a nation, we are not appalled.

When I look to the airline industry for analogies, as I often do, the Boeing 787 “Dreamliner” comes to mind.

After only a couple of incidents, the federal government grounded this newest, most technically sophisticated airliner until the problem was fully understood, the deficiency corrected, and the risk to passengers and crew minimized.

Shouldn’t we address surgical “never events”, which affect 4,160 patients each year, with the same urgency and gravity that we address the potential risk to 210-270 passengers of travelling in the “Dreamliner”?

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

Those are some of the findings from a survey of 900 practicing registered nurses by the ANA and GE Healthcare. The survey, which queried 500 nurses in the United States, 200 in the United Kingdom, and 200 in China, finds that few nurses would call their hospitals “safe.”

One of the most striking findings is the apparent chasm between the existence of hospital patient safety programs and their perceived effectiveness. For example, 94% of nurses surveyed say that their hospitals have programs in place that promote patient safety, which on the surface is great news; these programs are probably something that the execs at these institutions brag about.

However, nurses—90% of whom consider themselves most responsible for patient safety, over physicians (69%) and patient safety officers (60%)—don’t seem enthusiastic about the effectiveness of their hospital’s patient safety programs.

Only 41% of nurses describe the hospital they work in as “safe.” Just over half of nurses (57%) believe that the patient safety programs in their hospital are effective.

Whether these programs exist doesn’t seem to affect nurses’ perceptions of patient safety as much as the factors that affect how the programs are actually put in to practice. For example, in theory, patient safety programs might rely on error reporting and discussing these errors as a team.

In practice, however, error reporting often doesn’t occur because nurses are afraid they’ll be penalized for making mistakes. The survey found that although 90% of nurses say it’s important to have a culture where nurses are not penalized for reporting errors or near misses, 59% agree that nurses often hold back reporting patient errors in fear of punishment. Most nurses (62%) say the same about reporting near-misses.

Another key component of patient safety is open communication between nurses and their peers (and their leaders); nurses and physicians; and hospitals and patients.

But again, nurses identify a gap between theory and practice. Despite the prevalence of patient safety programs—and the communication that those programs presumably encourage—just 37% of nurses rated their hospital as excellent at communication with the patient. Even fewer nurses (31%) say their hospital is excellent at communication between staff.

For example, 33% of nurses said that that “poor communication among nurses at handoff” is something that has increased the risk of patient safety incidences in their hospital in the past 12 months, and 31% said “poor communication with doctors” has also increased the risk of patient safety incidents.

Another area where nurses crave more communication is technology. The survey finds that 74% of nurses say that technology/software patient safety initiatives exist in their hospitals. Although 59% of nurses say that patient safety data is collected and reported, they also say that there’s no follow-up or feedback given to the nurses.

Taken as a whole, these results seem to indicate that nurse leaders need to make a greater effort to really engage bedside nurses in patient safety initiatives, from development to implementation. Nurse leaders and executives should remember what Carolyn C. Scott, RN, M.Ed, MHA, vice president of performance improvement/quality for the Premier Healthcare Alliance, told me recently:

“There’re some incredibly creative and innovative bedside nurses in each and every organization. I’m always amazed at the ideas and the strategies that they’re even able to bring forward themselves; how to make something better.”

I recently read a very good article in the New York Times about a patient found to have the classic incidentaloma, a small mass in the adrenal gland. This is estimated to be seen in 4% of abdominal CT scans, and is rarely serious but typically leads to recommendations for additional testing and follow up CT scans to assure that it is not either a metastatic cancer from another area or a hormone secreting tumor of the adrenal gland itself. It is so common that the NIH has a formal recommendation article to guide physicians on how to manage a small adrenal mass found on imaging modalities, what they refer to as adrenal incidentaloma, and even have an acronym “AI.”

The term incidentaloma is a tongue-in-cheek to denote an incidental finding on an imaging test. –oma is the suffix used in the name of any tumor or enlargement. Examples are lipoma, condyloma, meningioma, teratoma, and dozens of others. The root of the term obviously refers to the fact that it was an incidental finding on a test looking for something else altogether.

Classic incidentalomas include:

Tiny solitary pulmonary nodules. Commonly on chest x-ray or chest CT scan a small pulmonary nodule is seen. Most times these are the result of a prior fungal infection or previous inflammation, but often require follow up imaging.

Small ovarian cysts seen on pelvic ultrasound. The ovaries of women of child bearing age form an ovulatory cyst each month, and commonly these normal cysts, or other small cysts of questionable importance are noted on pelvic ultrasounds done for evaluation of uterine fibroids, evaluation of abnormal bleeding, or other concerns where ovarian cyst or cancer is not the primary concern. Follow up ultrasounds, occasional surgery, and lots of emotional angst are the most common outcomes.

Renal cysts. Abdominal CT scans often show “lesions” in the kidney that require further evaluation to determine if they are simple renal cysts or possibly solid tumors. They usually are cysts, but are common incidental findings on CT scans done to look for kidney stones, diverticulitis, or other problems. Again additional evaluation with ultrasound and sometimes monitoring over time or even biopsy are done to further evaluate these incidentalomas.

Lab test abnormalities, though not referred to as incidentalomas are other common incidental findings that often lead to a cascade of follow up testing. The most common example in my practice is minor elevation of liver enzymes called transaminases, or liver function tests. When abnormal these are usually repeated along with testing for viral hepatitis C and B. If they remain abnormal liver imaging, sometimes liver biopsy are often done. The usual outcome is a diagnosis of fatty liver, with advice to stop drinking alcohol, and lose weight. This is advice that could have been given without even knowing the liver enzymes were elevated.

The whole incidentaloma problem is just one example of the real cost of ordering tests, especially tests like CT scans and MRIs that are so sensitive that they often find insignificant minor abnormalities or normal variants that lead to yet more expensive and sometimes invasive evaluation.

The 1,782 page Francis report into the Mid Staffs tragedy is a mass of detail. Hugely disturbing detail, you can’t fail to be moved by the evidence. But Francis, perhaps because he has a legal mind, doesn’t get behind the facts; he doesn’t question assumptions, he doesn’t even open the door to matters of theory.

As a consequence his recommendations represent what we would call single-loop thinking. The NHS is subject to massive amounts of regulation, but Francis recommends more, wrong thing righter. He recommends a ‘zero tolerance’ approach to breaches of fundamental standards but doesn’t question why the system as currently managed, might produce such neglect. He calls for a culture that puts patients first, but doesn’t consider why the current system fails in this regard.

If it is true that we have reached a level of dystopia that requires us to articulate a ‘structure of clearly understood fundamental standards’ – his top recommendation – we should despair. He thinks inspection for compliance will drive sufficient fear amongst healthcare professionals, yet he points to the fear culture that is already pervasive and dysfunctional. He argues for openness and transparency but fails to understand that the current use of gagging clauses (which he says should be banned) and shocking treatment of treatment of whistle-blowers is, too, symptomatic of the culture of fear. He does nothing to explain the reasons we have a culture of fear.

Francis thinks the answer is training, failing to appreciate how the current system drives peoples’ behaviour. He thinks that better leadership will instil a better culture, without understanding what currently drives leaders’ behaviour. Like Ed Balls did with social care, he recommends the creation of a leadership college, as though we can train that too. He thinks better information and benchmarking will act as a stimulus to improvement, showing no understanding of how benchmarking will lead to mediocrity, not innovation. It is perhaps ironic that the Francis recommendations on health improvement treat the symptoms, not the causes.

When Francis gets close to the causes: acknowledging a form-filling, target- and cost-driven culture, he fails to question them. He cannot see that form-filling bears no relation to and will detract from quality, he doesn’t know what targets do to systems and why, he wouldn’t believe that a focus on costs is driving costs up. Francis has a legal mind. He gave us the facts. You should read his report; you will be moved.

Politicians move in

The minister for health, Jeremy Hunt, takes up the Francis theme on excessive box-ticking, bureaucracy and burdensome regulation by announcing a talking-shop whose purpose is to reduce the regulatory burden by a third. I can hear Deming in my head: ‘why a third? Is it the right third? Why is it not two thirds? What benefit ensues against the cost of compliance? The best we can expect is less of the wrong thing; that’s still the wrong thing.

The right way to have gone would have been to order all leaders in the NHS to review their box-ticking and form-filling to ask: what of any of this is important to us in understanding and improving healthcare? And thus NHS leaders would make their own decisions about changing the nature of control and, as a necessary and urgent consequence, the nature of regulation.

The minister says we need a culture that puts the patient first, not knowing how the current system obviates any attempt to do that and announced a review of complaints procedures. You couldn’t make it up really; it is as though he read the Beano guide to management.

The prime minister, David Cameron, strides in with announcements about handing the Francis report to the police in order to find people to blame, giving performance-related-pay to nurses, sacking the bad ‘uns and making nurses fill in forms to prove they have spoken to every patient every hour. Clueless, wrong and damaging.

In short, while the minister promises to remove the dead hand of micro-management from crushing people, the hand is, in fact, warming up for BOHICA (bend over, here it comes again).

Closing one of his presentations with a literary flourish, the minister said: “Let me finish with words from TS Eliot we should not forget, when he said, “It is impossible to design a system so perfect that no one needs to be good.”

I’m no literary expert, but when I read Eliot’s ‘Choruses from the Rock’, I experience a man regretting society’s alienation from God; in the NHS, alienation from a worthy purpose:

‘What have we to do but stand with empty hands and palms turned upwards in an age which advances progressively backwards?’

Eliot (writing in 1934) describes how man is facing a tremendous flood of meaninglessness because context has been removed. Man has created an artificial world based on the new gods of reason, money and power. This is what has happened in health, the minister and his predecessors are responsible for a system that worships false gods.

It’s the system, stupid

I went to be a ‘witness’ on the Moral Maze (Radio 4) to try my best to make this point. We have a choice: to run our organisations in ways that encourage bad behavior, or in ways that encourage good; behaviour is a product of the system. I say ‘try’ because, for those of you who don’t know, the Moral Maze is something of a bear-pit. Ex minister Michael Portillo was my ‘opponent’ – an intelligent man who, nevertheless, thinks a bit of fear is a good thing. Having roughed me up he was at least decent enough to acknowledge my arguments in the summing up.

Don Berwick is a world authority on patient safety. For two decades he led the US Institute for Health Improvement and he led the US president’s “Obamacare” reforms. In 2011 was forced to resign that post, partly for referring to the NHS as an example for the US to follow.

In 2008 he was quietly commissioned to report on the culture of the NHS by the then Chief Medical Officer Liam Donaldson. He reported a climate of “fear” but this did not become public until the Francis Inquiry into the Mid Staffordshire scandal.

Last month David Cameron announced Don Berwick had been asked to become NHS Patient Safety Tsar to lead a panel “to make zero harm a reality in our NHS”. Don’t be surprised if their recommendations run counter to the government’s ‘reform’ agenda.

In July 2008 Don Berwick wrote a 60th birthday message to the NHS in the British Medical Journal. In it he made ten suggestions for improving the NHS. His advice was so good, and so prefigures the Francis Report, that I thought I’d share it.

“First, put the patient at the center – at the absolute center of your system of care”. Berwick argues for “the active presence of patients, families, and communities in the design, management, assessment, and improvement of care, itself” rather than any reliance on focus groups or surveys.

“Second, stop restructuring.” In an echo of Francis he warns that it is destructive of time and confidence and leads to risk averse healthcare. Stability, he says, helps change “become easier and faster, as the good, smart, committed people of the NHS – the one million wonderful people who can carry you into the future – find the confidence to try improvements without fearing the next earthquake.”

“Third, strengthen the local health care systems – community care systems – as a whole.” Health economies, not the fragmentation into individual elements like hospitals, clinics, surgeries, should become the “core of design”.

“Fourth, to help do that, reinvest in general practice and primary care”. Berwick describes general practice, not the hospital, as “the jewel in the crown of the NHS”.

“Fifth, please don’t put your faith in market forces.” I’m not sure David Cameron read this bit before appointing him. Berwick scathingly says: “It’s a popular idea: that Adam Smith’s invisible hand would do a better job of designing care than leaders with plans can. I do not agree. I find little evidence anywhere that market forces, bluntly used, that is, consumer choice among an array of products with competitors’ fighting it out, leads to the health care system you want and need. In the US, competition has become toxic; it is a major reason for our duplicative, supply-driven, fragmented care system. “

“Sixth, avoid supply-driven care like the plague.” He warns, rightly, that the pursuit of institutional self-interest has helped make healthcare unaffordable in the USA

“Seventh, develop an integrated approach to the assessment, assurance, and improvement of quality.” He warned we needed a coherent system of “aim-setting, oversight, and assistance.” As Francis also discovered.

“Eighth, heal the divide among the professions, the managers, and the government.” This was another theme of the Mid Staffs report, made much worse by the rise of “general management” after the Griffiths Report of 1983. Berwick warned, again echoed by Francis, that “the NHS and the people it serves can ill afford another decade of misunderstanding and suspicion between the professions, on the one hand, and the managers and public servants, on the other hand.”

“Ninth, train your health care workforce for the future, not the past.” The new skills we need are those in “patient safety, continual improvement, teamwork, measurement, and patient-centered care”.

“Tenth, and finally, aim for health.” He warns that “great health care, technically delimited, cannot alone produce great health”, and goes on: “Developed nations that forget that suffer the embarrassment of growing investments in health care with declining indices of health. The charismatic epidemics of SARS, mad cow, and influenza cannot hold a candle to the damage of the durable ones of obesity, violence, depression, substance abuse, and physical inactivity.”

Don Berwick concluded the article by writing: “The only sentiment that exceeds my admiration for the NHS is my hope for the NHS. I hope that you will never, never give up on what you have begun. I hope that you realize and reaffirm how badly you need, how badly the world needs, an example at scale of a health system that is universal, accessible, excellent, and free at the point of care – a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just. Happy birthday!”

Don Berwick’s own publications are a joy to read. You can also hear him in these two short videos. The first, ironically, was posted by an American free market think tank aiming to discredit him as being too left wing: it is indeed a brilliant two-minute defence of the NHS. The second summarises some key themes for good healthcare.

In commercial aviation, the last passenger fatality on a large U.S. jet was more than a decade ago. In health care, there may be as many as 200,000 preventable deaths each year in this country alone. We must stop thinking of these as unavoidable, and instead think of them as unimaginable.

Long before I became known for the Hudson River landing of US Airways Flight 1549, I had spent my professional life becoming expert at the science of safety. Decades in the cockpit, combined with years of airline safety work as an accident investigator and an airline crew instructor, taught me that good outcomes are the result of reliable systems, good leadership, consistent use of best practices, clear communication – and years of preparation. It doesn’t matter if your domain is the cockpit or the operating room: safety requires a system and a culture that must be learned and practiced by every member of the team. And that is why I so strongly believe that there is much our health care system can learn from the impressive system and culture of safety that have been developed in the airline industry.

How can two seemingly disparate worlds be connected? Consider that aviation and health care are both high-risk, complex, evidence-based domains that require high-level human performance. Now contrast the safety records of these two fields. In commercial aviation, the last passenger fatality on a large U.S. jet was in November 2001, more than a decade ago. Not so in health care. As we know from the Institute of Medicine reports and others, there may be as many as 200,000 preventable deaths each year in this country alone, including deaths resulting from what are considered to be medical errors – but are really system failures – and health-care-associated conditions. That’s the equivalent of 20 large jetliners crashing a week with no survivors, nearly 3 a day. After about the second day, we would see what we had after September 11, 2001 – a nationwide ground stop. There would be a Presidential commission, Congressional hearings; the National Transportation Safety Board (NTSB) would search out causes. No one would fly until we had solved the problems. Because airline accidents are very rare, they involve many people at once, they are noteworthy and newsworthy, we have achieved in aviation the public awareness and the political will to act. And that’s what’s lacking currently in medicine, along with leadership and direction, and a real sense of urgency, to address a problem that is systemic, huge and immediate. There are many who still think of these deaths as an unavoidable consequence of providing care. We must stop thinking of them as unavoidable, and instead think of them as unimaginable.

One remedy would be the establishment of an entity like the NTSB to investigate select, representative medical failures. (See An NTSB for Health Care — Learning From Innovation: Debate and Innovate or Capitulate). This, I believe, would help move medicine from the current blame-based system to a learning-based system in which accountability and learning are fairly and accurately balanced, and people feel free to report not only their own mistakes but system deficiencies that might lead to an accident. Through the NTSB the aviation industry has a formal lessons learned process. It comes up with probable causes and contributing factors. It makes recommendations to the rule makers and the industry about how to prevent a recurrence. This information is globally disseminated, but locally actionable.

Another remedy is to change the culture involving what I call human skills. In the old days of aviation, captains could be gods and cowboys. They often ruled their cockpits by whim, according to idiosyncrasies and preferences, with little consideration of best practices. If someone spoke to a captain about an unsafe practice, they put their jobs on the line. Thankfully, those days are long gone. We have achieved much better standardization; we have taught captains that they have to be the builders and leaders of teams; we set the tone, we create an environment of psychological safety, where there are no stupid questions, where we create a shared sense of responsibility for the outcome. It’s not about who’s right, it’s about what’s right. And paradoxically, it’s this reliability, this standardization of processes that becomes the firm base on which we can innovate when we face the unexpected. That’s what my crew and I did on Flight 1549. This was something we never trained for, it was something we had never envisioned, and we had 208 seconds to solve this life-threatening problem we had never seen before.

For more than a hundred years now, we have been learning important lessons at great cost, many of them literally bought in blood. Almost everything we know in aviation, every procedure, every rule, we have because people have died. All these lessons that have finally made aviation so ultra-safe, we are now offering up to medicine for the taking.

What would it take for health care systems to adopt some of the practices of aviation? If there were a national reporting agency for medical errors and near misses, would you be more likely to report? Tell us what you think in the Comment box below.

Best known as the hero pilot from the “Miracle on the Hudson,” Chesley B. “Sully” Sullenberger III has been dedicated to the pursuit of safety for his entire adult life. An aviation safety expert and accident investigator, Mr. Sullenberger serves as a CBS News Aviation and Safety Expert, as well as founder and chief executive officer of Safety Reliability Methods, Inc., a company dedicated to management, safety, performance, and reliability consulting. He is also on the editorial board of the Journal of Patient Safety and a member of the Greenlight Group, a team of world class experts supporting a number of global health care research and development initiatives.